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Volume
2:
Special Issue, November 2005
ORIGINAL RESEARCH
Perceived Likelihood of
Developing Diabetes Among High-Risk Oregonians
Angela M. Kemple, MS, Amy I. Zlot, MPH, Richard F. Leman, MD
Suggested citation for this article: Kemple AM, Zlot AI, Leman RF.
Perceived likelihood of developing diabetes among high-risk Oregonians. Prev
Chronic Dis [serial online] 2005 Nov [date cited]. Available from:
URL: http://www.cdc.gov/pcd/issues/2005/
nov/05_0067.htm
PEER REVIEWED
Abstract
Introduction
Prevention of diabetes in people at highest risk for developing the disease
is an important public health opportunity, considering the disease’s increasing
prevalence, its devastating impact on health and its high economic cost, the
availability of efficacious and cost-effective treatments to reduce
complications, and recent evidence that it can be delayed or prevented with
lifestyle interventions.
Methods
The Oregon Diabetes Prevention and
Control Program collected and analyzed responses from a statewide telephone
survey conducted in 2003 to determine whether Oregon adults at highest risk for diabetes 1) believed that they
were at risk for developing diabetes in the future, 2) had talked with a
health care professional about diabetes, and 3) had been tested for the
disease. Pearson chi-square tests and logistic regression analyses were
conducted to identify independent associations of select characteristics with
the study factors of interest.
Results
Even among respondents at highest risk for developing diabetes, at most
one third reported being concerned about developing diabetes, one fifth
reported having discussed their risk with a health professional in the
previous year, and less than half reported having been tested for diabetes by
a health provider in the previous year. After adjusting for multiple factors,
we found that having a family history of diabetes was
consistently associated with perceived risk of developing diabetes,
discussion about diabetes with a health professional, and diabetes testing.
Conclusion
Many Oregon adults at high risk for developing diabetes are unconcerned
about their risk for developing the disease, and few have discussed their risk of
diabetes with a health professional. Findings from this study suggest the need
for increased recognition of future diabetes risk by high-risk individuals and
health professionals to help translate diabetes
prevention into practice.
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Introduction
Diabetes is a growing public health problem. Nationally, the prevalence of
diabetes increased almost 50% during the previous decade (1). In Oregon, the
percentage of adults who reported having been told by a doctor that they had
diabetes increased from 4% in 1995 to 6% in 2003 (2). Diabetes is associated
with morbidity and mortality; it is a leading cause of death and
is associated with new cases of end-stage renal disease, lower limb
amputations, blindness, and cardiovascular disease (3). It is a chronic,
progressive, degenerative disease that has devastating effects on quality of
life and results in high costs for individuals and society because of its complications, hospitalizations, and lost productivity (3). When the disease
is diagnosed, diabetes complications can be reduced through evidence-based, cost-effective treatment strategies, but often these
treatments are underused (3).
Additional increases in diabetes prevalence are likely in light of
projected changes in the age and racial and ethnic composition of the U.S. population,
overall population growth, and increasing numbers of people who are
overweight, obese, or less physically active (3,4). Fortunately, the recent
success of major diabetes prevention trials demonstrates that development of
type 2 diabetes can be delayed and in some cases prevented in high-risk
individuals through lifestyle modifications such as modest weight reduction
and regular physical activity (5,6).
Risk factors for type 2 diabetes are well established and include older
age, obesity, family history of diabetes, prior history of gestational
diabetes, history of bearing an infant weighing 9 lb or more at birth,
physical inactivity, and prediabetes (a condition in which blood glucose
levels are elevated, although not enough to meet the diagnostic criteria for
diabetes) (7). In addition, type 2 diabetes is more common among African
Americans, Hispanic and Latino Americans, American Indians, and some Asian
Americans and Pacific Islanders than among non-Hispanic whites (7).
More recently, recognition of populations at higher risk for developing
prediabetes has been increasing. People who are both overweight (body mass
index [BMI] ≥25.0 kg/m2) and aged 45 years and older are at
particularly high risk (8). Younger overweight individuals who have additional
risk factors for type 2 diabetes are also at increased risk (8). It is
estimated that almost one fourth of overweight adults aged 45 to 74 years —
12 million nationwide — have prediabetes (9). Based on estimates from the
Behavioral Risk Factor Surveillance System (BRFSS) surveys, 673,000 Oregonians
are 45 years and older and overweight. As many as 152,000 of these individuals
may have prediabetes and could benefit from interventions to help them avoid
developing type 2 diabetes (10).
Prevention of diabetes in high-risk people is an important
opportunity for public health professionals. Diabetes prevalence is increasing
because of contemporary lifestyle changes (1,3,4), and the disease shortens
life expectancy and has devastating effects on quality of life (3). Effective
and economical treatment strategies exist to reduce complications in people
who already have been diagnosed with diabetes (3), and recent evidence shows
that type 2 diabetes can be delayed or prevented with lifestyle interventions
that have ancillary benefits (5,6). Increasing awareness of primary prevention
strategies in people at highest risk for diabetes and effectively promoting
prevention interventions in medical and community settings will be a
challenge. More information is needed about perceptions of diabetes risk and
prevention in high-risk individuals and among health care professionals.
In this study, the Oregon Diabetes Prevention and Control Program collected
and analyzed responses from a statewide telephone survey conducted in 2003 to
determine whether Oregon adults at highest risk for diabetes 1) believed that
they were at risk for developing diabetes in the future, 2) had talked with a
health care professional about diabetes, and 3) had been tested for the
disease.
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Methods
Information on Oregon adults’ perceptions of diabetes risk and prevention
was collected from Oregon’s 2003 BRFSS, a state-based, random-digit–dialed
household telephone survey. A disproportionate stratified sample design was
used to obtain a probability sample of the noninstitutionalized, adult
population aged 18 years and older in Oregon (11).
Survey measures
Initially, survey respondents were asked whether a doctor had ever told
them they had diabetes. Respondents considered not to have diabetes (which
included women who were told they had diabetes only during pregnancy) were
asked a series of questions about diabetes risk factors, their perceived risk
of developing diabetes, and any diabetes-related discussions or testing that had
occurred in the health care setting (Table
1).
Respondents were also asked about their extent of participation in moderate
or vigorous activity in a usual week. Information about physical activity was
collected using the standard BRFSS physical activity core module (12).
Respondents were categorized by physical activity levels as follows: 1) met
Centers for Disease Control and Prevention (CDC) recommendations (either
moderate-intensity activity during leisure time for 30 minutes or more on 5 or
more days per week or vigorous physical activity during leisure time for 20
minutes or more on 3 or more days per week; 2) insufficient activity (some physical
activity but not enough to meet CDC recommendations); or 3) inactive (less
than 10 minutes of moderate-intensity physical activity during leisure time in
a usual week). BMI was calculated based on self-reported height and weight and
was categorized as follows: 1) healthy weight (BMI <25.0 kg/m2),
2) overweight (BMI 25.0–29.9 kg/m2), or obese (BMI ≥30.0
kg/m2).
High-risk groups assessed included people with a family history of
diabetes, people who were overweight or obese, people who were physically
inactive, people who were aged 45 years and older, and people of Hispanic or Latino
ethnicity. Data for racial and ethnic populations other than non-Hispanic whites
or Hispanics and Latinos were combined because when analyzed separately, the
sample was too small for meaningful analysis. Respondents also indicated
whether a doctor, a nurse, or another health professional had ever told them
they had high blood pressure or high cholesterol.
We assessed separately the group that was overweight and aged 45 years and
older because this group is at particularly high risk for prediabetes, and
diabetes testing for people in this group is highly recommended (8). The total
number of risk factors commonly associated with diabetes was also determined
for each respondent without diabetes (including ages 45 years and older,
obesity, a family history of diabetes, and inactivity). Education level and
annual household income were also specified for each respondent.
Table 2 shows
the risk factor categories and select characteristics.
Three survey questions were used to assess the relationship between the
primary outcomes of interest (diabetes risk perception, diabetes discussions
with a health care professional, and diabetes testing) and access to medical
care. Respondents were asked to answer yes or no to the following questions:
- Do you have any kind of health care coverage, including health
insurance, prepaid plans such as HMOs, or government plans such as Medicare?
- Do you have one person you think of as your personal doctor or health
care provider?
- Was there a time during the last 12 months when you needed to see a
doctor but could not because of the cost?
Data analysis
Before analyzing the data, we weighted the sample responses to adjust for
differences in probability of selection and nonresponse and to derive estimates
that more accurately reflect the population from which the sample was drawn
(i.e., adult Oregonians as of July 1, 2003) (13). Pearson chi-square tests
were used to explore associations among perceived risk for diabetes,
discussion of diabetes with health care professionals, diabetes testing, and the
presence or absence of diabetes risk factors. Logistic regression analysis was
used to assess significant univariate factors to determine the independent
effect of important risk factors on each of the outcomes. Respondents who
reported “don’t know” or refused to answer questions were excluded from
analysis. Percentages, odds ratios (ORs), and 95% confidence intervals (CIs)
were calculated using the survey analysis procedures in STATA software,
version 7 (StataCorp LP, College Station, Tex). The Taylor series linearization
method was used to compute the variance of survey estimates that were
appropriate for the complex sample design.
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Results
Based on the Council of American Survey Research Organizations response
rate formula, the proportion of all eligible respondents in the sample for whom an
interview was completed was 50% (14). A total of 1974 respondents
completed telephone interviews, and 1810 (92.7%) reported that they had not
been diagnosed with diabetes; 21 (1.1%) women reported that they had been
diagnosed only during pregnancy, so these women were considered not to have
diabetes. The remaining 141 adults (6.2%) who reported having been told by a
doctor that they had diabetes and 2 adults with unknown diabetes status were
excluded from additional analyses.
Among respondents without known diabetes, 51.3% were women, and the mean
age was 45 years (range 18 to 99 years). The majority (84.7%) reported being
non-Hispanic white; 30.4% had completed high school but did not go on to
college, and 59.6% had some college education. Household earnings assessments
revealed that 31.6% had an annual household income of $25,000 to $49,999, and
35.3% earned $50,000 or more. Respondent access to medical care was as
follows: 80.4% had some form of health care coverage, 75.1% had at least one
person they thought of as their personal doctor or health care provider, and
14.5% reported they were unable to seek medical care at some time in the
previous 12 months because of cost.
The distribution of selected risk factors for diabetes and prediabetes was
as follows: 27.5% had a family history of diabetes, 37.7% were overweight,
20.6% were obese, 36.9% were insufficiently active during leisure time, and
10.7% were inactive during leisure time. Comorbidities that increase the risk
of diabetes complications were common: 20.5% had been told by a doctor, a
nurse, or another health professional that they had high blood pressure; 33.5%
reported being told by a doctor, a nurse, or another health professional that
they had high cholesterol; and 21.7% were current smokers. When four common
risk factors (ages 45 years and older, obesity, a family history of diabetes,
and inactivity) were analyzed together, 32.1% had none of these risk
factors, 38.3% had one, 21.7% had two, and 7.9% had three or four. In
addition, 19.8% were aged 45 years and older and overweight.
Overall, only 14.5% of respondents were at least somewhat or very worried
about developing diabetes in the next 10 years, 11.4% had talked about diabetes
with a health care professional in the previous year, and 25.6% had been
tested for diabetes by a health care provider in the previous year (Table 2).
Significant associations were found among all three factors of interest (Table
1).
Perceived risk of developing diabetes
Results from the bivariate analysis (Table
3) show that the likelihood of
being concerned about developing diabetes was higher among respondents who
were women, were Hispanic or Latino, were obese, were insufficiently active or
physically inactive, had not been able to see a doctor at some time in the
previous 12 months because of cost, and had a family history of diabetes.
Respondents aged 65 years and older and those with more than a high school
education were less likely to be worried. Respondents with two or more risk
factors for diabetes were more likely than those with fewer risk factors to be
worried about developing diabetes in the future. In no group did more than 34% of
respondents express concern about their risk of developing diabetes in the
future.
After including all significant variables in a single logistic regression
model, a family history of diabetes (OR 4.7 [95% CI, 3.3–6.7]), obesity (OR 2.8
[95% CI, 1.8–4.4]), being Hispanic or Latino (OR 2.6 [95% CI, 1.3–5.2]), being insufficiently
active (OR 1.6 [95% CI, 1.1–2.3]), and being a woman (OR 1.6 [95% CI, 1.1–2.3]) were all
independently associated with concern about developing diabetes in the next 10
years. Respondents aged 65 years and older were less likely to be worried about
developing diabetes in the future than those aged 18 to 44 years (OR 0.2 [95%
CI, 0.1–0.4]).
Diabetes discussion with a health care professional
Bivariate analyses (Table 4) indicate that the likelihood of talking with
a health care professional in the previous year about diabetes was higher
among respondents who were women, had a family history of diabetes, were
obese, had a history of high blood pressure, and had a personal health care provider. The
likelihood of discussing diabetes with a health care professional also
increased with increasing number of risk factors for diabetes. After adjusting
for multiple factors, a family history of diabetes (OR 2.9 [95% CI, 2.0–4.1]),
being a woman (OR 1.8 [95% CI, 1.2–2.6]), and obesity (OR 1.6 [95% CI, 1.1–2.5]) were still
independently associated with a history of talking with a health care
professional in the previous year about diabetes.
Diabetes testing
Findings from bivariate analyses (Table
5) show that the likelihood of
being tested for diabetes by a health care provider in the previous year was
higher among respondents who were women, were aged 45 years and older, were
overweight or obese, had a history of high blood pressure or high cholesterol, had health
care coverage, had a personal health care provider, and had a family history
of diabetes. The likelihood of being tested increased with increasing number
of risk factors for diabetes. Respondents who were aged 45 years and older and
overweight were also more likely to
have been tested for diabetes in the previous year than respondents who did
not have this combination of risk factors for prediabetes. Three of the risk factors were
independently associated with diabetes testing by a health care provider in
the previous year: a family history of diabetes (OR 2.0 [95% CI, 1.5–2.8]), ages 65
years and older (OR 1.9 [95% CI, 1.3–2.8]), and a history of high blood
pressure (OR 1.5 [95% CI, 1.1–2.1]).
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Discussion
To help translate primary diabetes prevention into practice, at-risk
individuals and health care professionals must be aware of the risk factors
for developing diabetes, talk to each other about diabetes,
test for evidence of prediabetes, and begin preventive interventions. However,
even among respondents in this study at highest risk for diabetes, at most one
third reported being concerned about developing diabetes, one fifth reported
having discussed their risk with a health professional in the previous year,
and less than half reported having been tested for diabetes by a health
provider in the previous year. Although our results show that respondents with
more risk factors tended to be more aware of their risk for diabetes, fewer than one third of people at highest risk (i.e., those
with three or four risk factors) were worried about developing diabetes in the
future. These findings about risk perception are similar to findings from
previous studies in the general population, which suggest that individuals
tend to underestimate their risk for developing diabetes (15-17).
Discussing diabetes with a health care professional and testing for
diabetes were also more likely among individuals with several diabetes risk factors.
We are unsure whether these associations reflect more frequent health care
visits because of the number of risk factors or result from respondents’
risk perceptions. Although we were able to determine that adults who were
worried about developing diabetes were more likely to talk with a health care
professional and be tested for diabetes (Table 1), we were unable to determine
the number of health care visits made.
Even though the American Diabetes Association recommends that fasting blood
glucose or glucose tolerance testing should be considered for all individuals
aged 45 years and older (8), our results show that respondents aged 45 to 64
years were no more likely to be worried about developing diabetes or to discuss
diabetes risk with a health care professional than their younger counterparts.
Respondents aged 65 and older were even less concerned. However, testing for
diabetes did increase with increasing age.
Although obesity was consistently associated with increased perceived
risk, being overweight was not independently associated. In addition, the
respondents who were overweight and aged 45 years and older (a group at
particularly high risk of developing prediabetes [8]) were no more likely to
perceive being at risk for diabetes than younger respondents
who were not overweight. Furthermore, this high-risk group was no more likely
to report discussing diabetes risk with a health professional. In contrast,
Harwell et al reported that among adults aged 45 years and older, being
overweight was independently associated with perceived risk for developing
diabetes and was also associated with having received medical advice regarding
diabetes risk (16). In our study, the group of respondents that was overweight
and aged 45 years and older was more likely to report having been tested for
diabetes, a finding that is also different from that of another study by
Harwell et al (18).
Even though older adults (aged 45 years and older) and the group that was overweight and
aged 45 years and
older were no more likely to be concerned about developing diabetes than their
lower risk counterparts, the increased likelihood of testing among these
high-risk groups may partly reflect health care providers’ recognition that
these adults are at higher risk for prediabetes and diabetes. Lower reported
levels of perceived risk may also result from high-risk adults who have
already been tested and not been diagnosed with diabetes.
Previous research has reported a twofold to sixfold higher risk of
developing type 2 diabetes among individuals with a family history of diabetes
compared with people who have no family history of diabetes (19). Although
family history was strongly associated with all three study questions,
among respondents with a family history the actual percentages of those who
reported being worried about developing diabetes (31%), having talked with a health
care professional (21%), and being tested for diabetes (38%) were still low. Pierce
et al reported that family members of individuals with type 2 diabetes
underestimate their own risk of developing diabetes (20). Another
population-based survey of adults aged 45 years and older also noted that
although perceived risk of developing diabetes was higher among respondents
with a family history of diabetes, less than half actually considered
themselves to be at risk (16).
Although Hispanic and Latino respondents were more worried about developing
diabetes than non-Hispanic whites, they were no more likely to have talked
with a health care professional about diabetes or to have been tested for
diabetes. These results may be related to decreased access to medical care
among Hispanics and Latinos. Additional analysis of Oregon's 2003 BRFSS revealed that Hispanic and
Latino respondents were significantly less likely (48.1%) than non-Hispanic
whites (84.4%) to have any kind of health care coverage or to have one person
they thought of as their personal doctor or health care provider (47.5% vs
79.2%); they were significantly more likely (23.8%) than non-Hispanic whites
(13.1%) to have had a time during the past 12 months when they were unable to seek
medical care because of cost (A.M.K., unpublished data, 2005). Although the
difference was not statistically significant, the low percentage of Hispanic
and Latino respondents who had discussed diabetes risk with health care
providers indicates the need for better access to medical care for these
individuals and culturally appropriate education for health care professionals
so that they will encourage diabetes discussions and testing.
The number of respondents was not sufficient to assess self-perceived risk
of diabetes among racial and ethnic groups other than non-Hispanic whites and
Hispanics and Latinos. Future research should explore diabetes perceptions and
awareness of its prevention among other racial and ethnic populations that are at
higher risk.
Discussing diabetes with a health care professional and diabetes testing
were not found to be independently associated with access to medical care. We
were unable to track the number of health care visits made to providers, which
may have been a better indicator of medical care access and may have been
associated with the major study factors of diabetes risk perception, diabetes
discussions with health care providers, and diabetes testing. A previous
population-based study on diabetes testing among adults aged 45 years and older
found that a history of two or more visits to a health care provider in the previous year
was independently associated with diabetes testing within the previous year
(18).
Limitations
All data were self-reported, which may have resulted in recall and
nonresponse bias, especially for questions about diabetes testing, frequency
and duration of physical activity, and weight and height used to compute BMI.
Moreover, individuals who have diabetes but have not been diagnosed or do not
remember being diagnosed may have been categorized as not having diabetes. The
sample only represents individuals living in households with land-based
telephones; individuals without telephones, those who used cellular phones
exclusively, and those who were institutionalized were not represented (11).
We only asked respondents whether they had talked with a health care
professional about diabetes or been tested for diabetes in the year preceding
the survey date. Because of this restricted time frame, we were unable to
obtain information about respondents who had been tested more than a year
before the survey date, had received a negative result, and were not due for
another test (8). If the time frame had been extended, the percentages of
adults who had talked with a health care professional and been tested for
diabetes may have been higher. In addition, among respondents who had been
tested for diabetes, we were unable to determine the type of test performed
(Table 1).
Several health behavior models describe the important impact of multiple
health beliefs such as perceived severity, outcome expectations,
self-efficacy, and perceived risk on an individual’s likelihood of
initiating a behavior change (21,22). In our study, BRFSS data were only
collected on one health belief: a person’s perceived risk for developing
diabetes. Additional research is needed to determine whether Oregon adults at
high risk for diabetes who are worried about developing diabetes actually believe
that their risk is serious, believe the benefits of taking action outweigh the
costs, believe they have the ability to change, and then actually make the
necessary lifestyle changes to decrease their risk.
The cross-sectional nature of this study may have restricted our
interpretation of certain findings. For example, certain high-risk
respondents, such as older adults, may not have been worried about developing
diabetes because they had already talked with a health care professional about
their risk, been tested for the disease, and received a negative result.
Prospective studies are needed to further elucidate the complex relationships
among the primary outcomes of interest: perceptions of diabetes risk,
discussions about
diabetes with a health care professional, and testing for diabetes.
Implications
Many Oregon adults at high risk for developing diabetes are unconcerned
about their risk for developing the disease. Findings from our study suggest
that high-risk individuals need to be more aware of their potential for
developing diabetes, as do their health care professionals — an initial step
toward translating diabetes prevention into practice. Effective public health messages about diabetes awareness could
be incorporated into educational and screening interventions targeted toward
populations at high risk for developing diabetes. These messages should
address the risk of developing diabetes, the value of discussing diabetes risk
with a health care professional, and ways to delay or even prevent the
condition from developing with fairly simple lifestyle changes. Although
health professionals are still designing targeted programs that identify
individuals at increased risk of developing prediabetes or diabetes and offer
appropriate education and screening strategies, findings from our study
provide support for the potential benefits of such programs.
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Acknowledgments
We thank Melvin A. Kohn, Jane M. Moore, and Jamie L. Waltz for their
thoughtful review of the final manuscript; Thomas W. Brundage for his review
of the data analysis; and Jennifer A. Woodward, Joyce A. Grant-Worley, and the
Behavioral Risk Factor Surveillance System staff members in the Oregon Center
for Health Statistics for coordinating the survey administration and data
collection.
This study was supported by Cooperative Agreement U32/CCU022726 between the
Oregon Department of Human Services (DHS) Diabetes Prevention and Control
Program and the Centers for Disease Control and Prevention (CDC). It was
also supported in part by Cooperative Agreement U58/CCU001998 between the
Oregon DHS Health Services and the Department of Health and Human Services,
Public Health Service, CDC. The contents of this manuscript are solely the
responsibility of the authors and do not necessarily represent the official
views of the CDC.
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Author Information
Corresponding Author: Angela M. Kemple, MS, Epidemiologist, Cardiovascular,
Diabetes, Nutrition, and Physical Activity Section, Washington State
Department of Health, PO Box 47855, 111 Israel Rd SW, Olympia, WA 98504-7855.
Telephone: 360-236-3652. E-mail:
angela.kemple@doh.wa.gov. At the time of the study, Ms. Kemple was a Research Analyst
with the Oregon
Department of Human Services, Diabetes Prevention and Control Program, Portland, Ore.
Author Affiliations: Amy I. Zlot, MPH, Genetics Program, and Richard F.
Leman, MD, Health Promotion and Chronic Disease Prevention Program, Oregon
Department of Human Services, Portland, Ore.
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